Cervical spine assessment

Cervical spine assessment

This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

All children under 16 years of age with major trauma (including confirmed or highly suspected spinal cord injury) should have ongoing management at Royal Children's Hospital. See
State Trauma Guidelines

In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, the earlier assistance can be dispatched to the hospital.

See also:

Major paediatric trauma – The primary survey

Background

Traumatic injuries of the cervical spine (C-spine) are uncommon in children. However, it is typical to assume there is a cervical spine injury until examination and/or radiological investigation demonstrate otherwise. It is often challenging to assess and immobilise children when a C-spine injury is
suspected.

Frequent reassurance is required to help keep the child still and reduce their anxiety levels.

If the child is anxious or uncooperative and a thorough examination is not possible, try and maintain in line C-spine immobilisation.

Early provision of simple analgesia (paracetamol / ibuprofen) and early review by a senior clinician who is experienced in the management of paediatric C-spine assessment may avoid prolonged periods in C-spine collars.

Patients requiring cervical spine immobilisation

Any patient with a history of trauma requires C-spine immobilisation, if the patient:

Is unconscious (GCS
<13)

Is complaining of neck pain or midline tenderness or has limitation of movement

Is using their hands to support neck

Has any neurological deficit

Has significant head /facial/upper torso injuries

Has traumatic torticollis

Is substance affected (not analgesia) with suspicious mechanism

Has any conditions known to predispose to C-spine injury including rheumatological, congenital, metabolic, genetic conditions or previous C-spine surgery. These patients may sustain C-spine injury with a less severe mechanism.

Note: ‘Distracting Injury’ is not a contraindication for removal of the cervical collar. Any injury below the upper torso should not be regarded as a distracting injury for the purpose of C-spine assessment.

Mechanism is more relevant in patients who are unable to be adequately assessed ie preverbal, disoriented/confused, developmental delay etc. Any patient who cannot be adequately assessed
for clinical signs AND could have any of the following mechanisms of injury
should be immobilised:

Pedestrian / cyclist hit > 30km/hr.

Passenger – MVA collision > 60km/hr.

Fall - more than 3 metres.

Kicked by, or fall from a horse.

Backed over by a car.

Thrown from vehicle.

Severe electric shock.

Immobilisation

Patients with suspected or
possible C-spine injury must have their neck immobilised until formal
assessment occurs.

Sand bags and tape are NOT recommended in the hospital setting

Spinal boards: all children should be taken off spinal board at time of transfer from ambulance trolley.

Thoracic Elevation Device
(TED): Children have a head which is disproportionately larger than their neck and bodies. When placed flat on a firm surface the size of the head tends to force the neck into flexion losing the desired neutral spine position and potentially obstructing the airway. Children less than 8 years should be placed on a TED.

Immobilisation
technique:

If any of the following apply, manual in-line immobilisation without a collar should be maintained:

Uncooperative patient - constant reassurance is required to reduce anxiety. If a thorough examination is not possible, seek senior assistance.

Infant/baby too small for one-piece collar

Child with traumatic torticollis (child with a significant injury will hold their neck in a position of comfort – maintain inline immobilisation in this position)

Ensure adequate analgesia is provided.

Occipital-cervical dissociation is more prevalent in children less than 8 age years of age and is not made stable by applying a collar. If a patient is intubated, unconscious or there is a high suspicion of this type of C-spine injury (e.g. in a high velocity motor vehicle accident) – lateral bolsters can
be applied (e.g. rolled up towels on each side of the patient’s head.) Sandbags/tape should NOT be used.

Assessment of the C-spine

If abnormal neurology – contact neurosurgery immediately

To be able to adequately assess the patient, he/she must:

Be conscious

Be cooperative

Not be affected by alcohol or recreational drugs

Be developmentally able to engage in the assessment process.

C-spine assessment, clearance and X-ray interpretation ought to be conducted in consultation with a senior clinician with sufficient experience in the assessment of the paediatric C-spine.

Prior to palpation, ask the patient if he/she has any neck pain, weakness, paralysis or paraesthesia with age appropriate questioning. If there is abnormal neurology, consult with Neurosurgery.

Whilst maintaining in-line immobilisation, gently palpate the posterior midline of the neck – feeling from the nuchal ridge to the 1st thoracic vertebra (The most prominent spinal process arises from the C7 vertebra). Repeat the process lateral to the midline on both sides. Tenderness laterally may indicate muscular or
soft tissue injury.

If there is no midline tenderness and no abnormal neurology, assess the active range of movement of the neck by asking the patient to slowly rotate his/her head 45 degrees to the left and right, stopping if this causes pain or abnormal sensations in their
arms.

If the patient is able to move the neck without pain and without developing any neurological symptoms, the collar may be removed, and the C-spine cleared.

If the assessment reveals midline C-spine tenderness or painful or limited neck movements, the cervical collar / immobilisation should be reapplied and X-rays obtained of the C-spine. X-rays should be reviewed by a senior clinician who has also examined the patient.

If the x-rays are normal and there has been resolution of the midline tenderness or limitation of movement, the C-spine can be cleared.

If patient is unable to be assessed, immobilisation should be maintained.

Radiology

Patients with signs and symptoms suggestive of possible C-spine injury or those with suspicious mechanism who cannot be reliably assessed, require plain x-rays.
It is imperative that the senior person making the clinical decision regarding clearing the c-spine has both examined the patient and viewed the films.
All patient transfers (on/off x-ray tables, CT scan etc.) must be done using a patient-slide, with clinical staff maintaining in-line immobilisation.
The collar and TED pad should remain in place with the patient during the cervical spine x-ray series.

Considerations

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is an outdated term, but refers to a patient sustaining significant injury without bony fractures. Therefore, a “normal” xray and CT does not exclude spinal injury. This occurs in children, predominantly less than eight years of age, and may be the result of lax ligamentous support and immature bony structures or cord ischemia due to vascular injury or hypoperfusion. The presence of neurological symptoms, even if there is a normal x-ray and normal CT, requires consultation with a senior Emergency Department doctor initially, and neurosurgery if required.

What to x-ray

≤5yrs = AP and lateral x-ray only

6yrs or older = AP, lateral and odontoid x-rays

Lateral X-rays should include Occiput to T1 (may require shoulder traction to visualize this level)

Lateral c-spine

Most important view.

Portable film can be taken (e.g.: in resuscitation bay)

If the cervico-thoracic C7-T1 junction has not been satisfactorily imaged, a single attempt at a swimmer’s view may be obtained.

Flexion and extension views should not be performed

AP and Odontoid (Peg) view

Non urgent - may be taken after priority CT imaging of other body regions if required

For odontoid view the collar may be opened – but ensure in line neck immobilisation is maintained.

Further imaging of C-Spine

Patients with abnormalities on plain c-spine x-rays should be discussed immediately with the orthopaedic team (RCH) or neurosurgical team (MMC).

All intubated patients requiring CT brain should be discussed with neurosurgery to see if a CT cervical spine is also indicated.

A normal CT of the cervical spine does not exclude injury in the unconscious patient and an MRI scan may be required.

Patients in whom the cranio-cervical or cervico-thoracic junction remain obscured after a single extra view should not have repeated attempts at plain imaging but have a CT of the relevant area

Reassessment

Patients with normal
x-rays should be reassessed clinicallyfor:

Posterior Midline Tenderness

Range of Motion of cervical spine

Flexion/extension

Lateral Flexion (left and right)

Lateral Rotation (left and right)

If there is no tenderness and afull range of motion is preserved then
the collar may be removed.

Patients with persistent posterior midline tenderness, or unable to be clinically assessed, but with normal x-rays of the cervical spine can be classified as below:

The Ambulant,
Otherwise Well Patient with Midline Tenderness +/- Decreased Range of Movement:

These patients should be placed in a 2 piece collar within 4 hours of arrival in ED

The patient may be discharged home wearing the 2 piece collar and reviewed clinically in the Orthopaedic Fracture clinic in 1-2 weeks.

If there is persistent midline tenderness at the 1-2 week follow-up

Spine can be deemed stable with normal flexion-extension x-rays, and the collar removed

- 2-piece collars should only be fitted by those staff trained to do so

Information specific for RCH

Documentation: Use the Major Trauma management record for documentation of spinal assessment and plan

Further imaging (including CT, MRI) must be discussed with the Emergency Consultant or Orthopaedic/Neurosurgery Registrar, and the Medical Imaging Fellow/Consultant.
Intubated patients requiring CT brain should be discussed with Neurosurgery.

Referrals:

Neurological Signs/Symptoms with C-spine injury or unable to assess in ED due to head injury = Neurosurgery

Patients with abnormal/equivocal Radiology (X-ray or MRI) or high clinical suspicion of C-spine injury = Orthopaedics.

Outpatient follow-up for ambulant patients = Orthopaedics

Admission:

Patients with multiple injuries are admitted under General Surgery with Neurosurgical and/or Orthopaedic input.
Patients with isolated spinal cord injury are admitted under Neurosurgery.

Information specific for monash health

The Neurosurgery Unit at Monash Children’s provides a service for assessment of paediatric patients with brain and spinal injuries. All patients with suspected injury should be discussed with the Neurosurgery Unit (03 9594 6666).